921: Childhood Mental Health Issues:

1. 921: Childhood Mental Health Issues: An Introduction for Resource Parents

2. Learning Objectives • Categorize mental health disorders such as emotional disorders, behavior disorders, and developmental disorders in children and adolescents. • Recognize the cultural issues and symptoms of commonly diagnosed mental health disorders in children and adolescents. • Identify the latest methods of treatment and assessment.

3. Competencies • The foster parent knows how to assist in treatment of children with mental health or behavioral disorders, including discussion of feelings and concerns, problem solving, empathic listening, behavior management, de-escalation, sanctioned physical restraint, and assault prevention. • The foster parent understands the counseling process, including relationship building, assessment, diagnosis and treatment, and can work with the child's therapist.

4. Statistics • 11.3 percent of U.S. children ages 2-17 (13.4 percent in PA) are reported by their parents to have been diagnosed with emotional, behavioral, or developmental conditions • ADHD was the most prevalent diagnosis among children ages 3-17 • Boys were more likely than girls to have ADHD, behavioral or conduct problems, autism spectrum disorder, anxiety, and Tourette Syndrome • Girls were more likely to be diagnosed with depression • Suicide is the second leading cause of death among children ages 12-17 (Centers for Disease Control and Prevention, 2013)

5. Categories of Child/Adolescent Mental Health Disorders • Neurodevelopmental Disorders • Autism Spectrum Disorder* • Attention Deficit Hyperactivity Disorder* • Depressive and Bipolar Disorders • Major Depressive Disorder* • Persistent Depressive Disorder (Dysthymia) • Bipolar Disorder • Disruptive Mood Dysregulation Disorder • Anxiety Disorders • Selective Mutism, Specific Phobia, Separation Anxiety*, Social Anxiety*, Panic Disorder, Agoraphobia, Generalized Anxiety

6. Categories of Child/Adolescent Mental Health Disorders • Disruptive, Impulse Control, and Conduct Disorders • Oppositional Defiant Disorder* • Intermittent Explosive Disorder • Conduct Disorder* • Trauma and Stressor-Related Disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Posttraumatic Stress Disorder • Feeding and Eating Disorders • Anorexia Nervosa • Bulimia Nervosa • Binge-Eating Disorder

7. Diagnosing • Psychological and/or psychiatric evaluation • Use Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) • Disorders listed under main categories • Arranged across the lifespan • Take into consideration cultural context • Identify frequency and intensity of emotions and behaviors • Do emotions/behaviors impair functioning? • Working, playing, loving, expecting well • (Garmezy, 1991)

8. Biopsychosocial Model • Temperamental • Easy, difficult, slow to warm up (Chess & Thomas, 1991) • Environmental • Family dynamics, parenting styles, larger social systems, adverse life stressors • Genetic and physiological • Predispositions • Physical health (American Psychiatric Association, 2013)

9. Resilience • Nature and nurture are intertwined • Internal and external risk and assets combine • 40 developmental assets • Search Institute • http://www.search-institute.org/developmental-assets/lists • Resilience is a dynamic process encompassing positive adaptation within the context of significant adversity (Henderson, 2003)

10. Childhood Mental Health and Treatment • Results from National Health and Nutritional Examination Survey (NHANES) • Half of children with mental health issues (50.6 percent) were not receiving treatment • View the video to learn about the results of the survey • http://www.youtube.com/watch?v=hOrR6CpRLCw • Children/adolescents with mental health issues need advocates to ensure that the right type of treatment is received, and that it is of sufficient frequency and duration to meet their needs! • All team members must be advocates

11. Team Approach to Treatment • Resource parents • Birth parents • Caseworker • Pediatrician • Psychologist and/or psychiatrist • Therapist • Educators • Speech and language therapist • Occupational therapist • Physical therapist

12. Collaborating as a Team Member • All members play an important role in gathering and sharing information on the strengths, challenges, needs, and underlying issues • All members’ perspectives and voices need to be heard in the change process to meet common goals • All members must be culturally aware and responsive to the child and family needs • All members are treated with dignity and respect

13. New Ideas: Section I • Statistics • Categories • Biopsychosocial model • Resilience • Teaming

14. Neurodevelopmental Disorders • Autism Spectrum Disorder (ASD) • Attention Deficit Disorder (ADHD)

15. ASD: Symptoms • Social communication and social interaction deficits • Social-emotional reciprocity • Nonverbal communication behaviors used for social interaction • Developing, maintaining, and understanding relationships • Restricted, repetitive behaviors, interests, or activities • Stereotyped or repetitive movements, use of objects, or speech • Insistence on sameness • Fixated interests • Hyper- or hypo-reactivity to sensory input (American Psychiatric Association, 2013)

16. ASD: Rates and Risks • 1 percent of child/adolescent population • Male to female ration of 4:1 • Environmental • Advanced parental age • Fetal exposure to toxins • Genetic • 15 percent of cases associated with genetic mutations • Multiple genes most likely involved (American Psychiatric Association, 2013)

17. ASD: Assessment and Treatment • Pediatricians are now using screening tools for ASD as early as 9 months to 24 months • No known “standard” of treatment • Combination of behavioral therapy, educational interventions and, when warranted, medication to treat specific symptoms such as sleeping difficultiesor anxiety

18. ASD: Interventions • Ensure that IFSP/IEP recommendations are followed • Consult with occupational therapist for sensory integration issues • Provide structure and routines • Provide transition cues • Use perseveration as a motivator • Don’t ask child to look and listen simultaneously • Use visual icons; many children with ASD think in pictures • Explain figures of speech; don’t use sarcasm

19. ADHD: Symptoms • Primary feature is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development • Present before age 12 and manifests in two or more settings • Three subtypes within the disorder • Predominantly Inattentive • Predominantly Hyperactive/Impulsive • Combined (American Psychiatric Association, 2013) • View the video and identify the signs of ADHD • http://www.youtube.com/watch?v=IgCL79Jv0lc

20. ADHD: Prevalence and Risk • 5 percent of children/adolescents diagnosed with ADHD • Girls most commonly diagnosed with inattentive subtype • Environmental • Low birth weight • History of maltreatment or multiple foster placements, drinking/smoking/toxin exposure (lead) during pregnancy • Genetic • Higher in first-degree relatives (American Psychiatric Association, 2013)

21. ADHD: Assessment and Treatment • Psychologists and psychiatrists use a number of tools • Parent or primary caregiver interview • Child interview • Connors Rating Scales completed by the primary caregiver(s) and teachers • Treatment • Individual/parent counseling • Academic accommodations • Cognitive behavioral therapy • Social skills training • Medication (stimulants, antidepressants)

22. ADHD: Interventions I • Inattention • Only give one direction at a time and only when in direct proximity with the child • Develop self-talk messages (“Get back on track!”) • Hyperactivity • Provide structured physical activity • Provide transition cues • Cue to use calming techniques • Soup breathing (inhale 3 seconds/exhale 6 seconds) • Tactile objects (touch a soft object) • Centering (brings knees to chest)

23. ADHD: Interventions II • Impulsive • Create think and do plans (think aloud) • Organization • Use color, pictures and apps for routines • Say, “You’re off track! What do you need to be doing?” Get dressed Eat breakfast Pack up for the bus

24. Affective Disorders and Posttraumatic Stress Disorder • Major Depressive Disorder (MDD) • Anxiety disorders • Separation anxiety • Social anxiety • Posttraumatic Stress Disorder

25. Depression: Symptoms • Decreased interest in activities; or inability to enjoy previously favorite activities • Hopelessness • Persistent boredom; low energy • Social isolation, poor communication • Low self-esteem and guilt • Extreme sensitivity to rejection or failure • Increased irritability, anger, or hostility • Difficulty with relationships • Frequent complaints of physical illnesses • Frequent absences from school or poor performance in school • Poor concentration • A major change in eating and/or sleeping patterns • Talk of or efforts to run away from home • Thoughts or expressions of suicide or self-destructive behavior (AACAP, 2013)

26. Depression: Recognize the Signs • Please watch the video Day for Night and identify how the adolescents describe the signs of depression • http://www.youtube.com/watch?v=QLxFSiKXYko

27. Depression: Prevalence and Risk • Major depression strikes 8 percent of youth ages 12 and older • More girls than boys in adolescence; equal rates in childhood • Three risk factors • Temperament (negative affectivity) • Environmental (adverse childhood experiences, particularly multiple experiences) • Genetic (two to four higher likelihood if first degree relative has depression) (American Psychiatric Association, 2013)

28. Depression: Assessment and Treatment • Psychological and/or psychiatric evaluation needed • Screening tools • Child Behavior Checklist • Beck Inventory • Comprehensive treatment often includes both individual, family therapy, and medication • Cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are forms of individual therapy • Antidepressant medication(SSRIs) most commonly prescribed • Paxil, Zoloft, and Prozac are most commonly used • Consult doctor if medication side effects occur • Medication dosage must be tapered off to avoid negative effects of abruptly stopping the medication

29. Warning Signs for Suicide • Talking about suicide • Getting the means to commit suicide • Withdrawing from social contact • Having mood swings • Preoccupation with death, dying or violence • Feeling trapped or hopeless about a situation • Increased use of alcohol or drugs • Changes in eating or sleeping patterns • Risky or self-destructive behaviors • Giving away belongings • Saying goodbye to people as if they won't be seen again (Mayo Clinic, 2012)

30. Anxiety Disorders: Common Threads • Excessive fear (emotional response to real or perceived imminent threat) • Anxiety (anticipation of future threat) • Behavioral responses (fight, flight, freeze) (American Psychiatric Association, 2013)

31. Anxiety Disorders: Prevalence and Risk Separation Anxiety Social Anxiety 7 percent Temperamental Fear of negative evaluation Environmental Maltreatment Modeling by parent Genetic 2-6 times greater chance in first-degree relatives (American Psychiatric Association, 2013) • Range of 2.8 percent to 8 percent • Environmental • Often develops after a life stress, especially loss • Parental overprotection • Genetic • Much greater risk in first-degree relatives • Exact rates unknown

32. Separation Anxiety: Symptoms • Excessive distress when anticipating or experiencing separation from home or from attachment figures • Excessive worry about • Losing attachment figures or possible harm to them • Experiencing an untoward event that causes separation from attachment figures • Being alone or without attachment figures • Reluctance or refusal to go out, away from home, to school • Reluctance or refusal to sleep alone • Nightmares with them of separation • Repeated complaints of physical symptoms (American Psychiatric Association, 2013)

33. Social Anxiety: Symptoms • Fear or anxiety about social situations with peers and adults (conversations, meeting people, performance in front others, being observed) • Fears of being negatively evaluated by others • Expressed in children through crying, tantrums, freezing, clinging, or failing to speak in social situations • Social situations are avoided or endured with intense fear or anxiety • Lasting for six months or more (American Psychiatric Association, 2013)

34. Anxiety Disorders: Assessment and Treatment • Assessment • Comprehensive evaluation by a psychologist and/or psychiatrist • Sometimes use self-report measures completed by both the parent and child (if the child is old enough to self report on symptoms) • Treatment • Cognitive behavioral therapy • Medication (antianxiety and antidepressant) • View video on combination of treatment approaches • http://www.webmd.com/balance/video/too-scared-social-anxiety-disorder

35. Anxiety Disorders: Interventions • Empathize with your child’s feelings • Stay calm when he becomes anxious about a situation or event • Recognize and praise her small accomplishments in handling anxiety and fear • Don’t punish mistakes or lack of progress • Be flexible and try to maintain a normal routine • Modify expectations during stressful periods • Plan for transitions (i.e. allow extra time in the morning if getting to school is difficult) (Anxiety and Depression Association in America, 2013)

36. Posttraumatic Stress Disorder: Symptoms and Interventions • Intrusion symptoms • Avoidance of stimuli associated with trauma • Changes in cognitions and mood • Marked changes in arousal and reactivity • Play therapy • Art therapy • Trauma-informed cognitive behavioral therapy

37. Disruptive, Impulse-Control, and Conduct Disorders • Oppositional Defiant Disorder (ODD) • Conduct Disorder (CD)

38. ODD: Symptoms • Angry/irritable mood • Often loses temper • Is often touchy or easily annoyed • Is often angry and resentful • Argumentative/defiant behavior • Argues with adults • Defies or refuses to comply with requests or rules • Deliberately annoys others • Blames others for mistakes • Vindictiveness/spiteful • At least four symptoms; symptoms present at least 6 months (American Psychiatric Association, 2013)

39. ODD: Prevalence and Risk • Rates range from 1 percent to 11 percent, with an average prevalence of 3.3 percent • More prevalent in families where child care is disrupted by a succession of different caregivers • More prevalent in families in which harsh, inconsistent, or neglectful child-rearing practices are used (American Psychiatric Association, 2013)

40. ODD: Assessment and Treatment • Assessment • No single test that can diagnose • Psychiatrist interviews parent and child to determine if the behaviors meet the criteria for a diagnosis of ODD • Treatment • Family therapy to build positive family interactions • Parenting skills training • Social skills training for the child • Conflict resolution and anger management skills for the child • Possibly medications to treat related mental health conditions, such as ADHD (AACAP, 2013)

41. ODD: Interventions • Forced choice • Shirt or pants first. Your choice. • Shower or bath. Your choice • Meat or potatoes. Your choice • Picking the “hills” to die on • Basket A (high priority; must be dealt with immediately) • Basket B (high priority; can be dealt with later) • Basket C (low priority; do you really want to go there?) • Positive reinforcement for delaying gratification • I noticed that…. I see that... (not I like how…) (Greene, 2010)

42. CD: Symptoms • Pattern of behavior in which the basic rights of others or societal norms and rules are violated • Behaviors fall into four categories • Aggression to people/animals • Destruction of property • Deceitfulness or theft • Serious violation of rules (American Psychiatric Association, 2013)

43. CD: Subtypes • Three subtypes • Childhood onset (prior to age 10) • Adolescent subtype (no symptoms prior to age 10) • Unspecified (not enough information to determine onset) • Code added if symptoms reflect limited prosocial emotions • Lack of remorse, empathy, concern about performance, or affect (American Psychiatric Association, 2013)

44. CD: Prevalence and Risk • Range of 2 percent to 10 percent; more boys than girls • Temperament • Difficult temperament; lower than average IQ • Environment • Neglect, abuse, frequent change in caregivers • Inconsistent, harsh discipline • Lack of supervision, parental criminality or substance abuse • Association with gangs and delinquent peer group • Genetics • Family history of depressive disorders, bipolar, ADHD, CD • Slower resting heart rate (American Psychiatric Association, 2013)

45. CD: Assessment and Treatment • Assessment • Psychological and/or psychiatric evaluation • Child Behavior Checklist • Treatment • Family therapy • Cognitive behavioral therapy • Anger management • No specific type of medication for CD • Medications used to treat co-existing conditions, such as depression, ADHD, or anxiety (AACAP, 2013)

46. CD: Interventions I • If child is capable of feeling empathy for others and remorse after violating the rights of others: • Build anger management skills • Trigger, correct interpretation, head talk/cool talk, calming techniques, problem solving skills • Correct attribution bias (view of intent in interactions) • Was it on purpose or accidental? • Promote making amends when rights of others are violated • Use logical consequences for stealing or destruction of property (reparations)

47. CD: Interventions II • If child is not capable of feeling empathy for others and remorse after violating the rights of others: • Clearly state the misbehavior, don’t ask why (will probably only lie to you), state the consequence, end the conversation • It will take extended time in therapy to help the child develop empathy for others • For a few adolescents, empathy never develops and they are at risk for the diagnosis of antisocial personality disorder in adulthood

48. New Ideas: Section II • Autism Spectrum Disorder • Attention Deficit Hyperactivity Disorder • Depression • Separation Anxiety Disorder • Social Anxiety Disorder • Posttraumatic Stress Disorder • Oppositional Defiant Disorder • Conduct Disorder

49. Resources • CHADD • http://www.chadd.org/ • Depression in Children and Adolescents (Fact Sheet) • http://www.nimh.nih.gov/health/publications/depression-in-children-and-adolescents/index.shtml • ODD: A Guide for Families • http://www.scribd.com/doc/127177972/A-Guide-for-Families-Oppositional-Defiant-Disorder-ODD